Violation Details: 00393431-AP-344073

Records Request Print
Date
4/3/2025
Report number
00393431-AP-344073
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about April 3, 2025, the facility failed to provide a safe medication administration system to ensure Alleged Victim’s (AV) blood thinner medication was administered as ordered. Based on facility documentation and interviews, AV missed several doses of his/her blood thinner medication that is to be taken by mouth every day for dinner for atrial fibrillation. Facility records indicated that facility did not have the medication on the MAR when a new medication administration software was implemented as far back as December 2024. The facility's failure to provide a safe medication administration system resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigated determined no abuse occurred by AP2.
Sanction
ALFCP25-00290 $1125.00 fine assessed